Texas Dual Eligible Medicare Plans, Simplified

If you have both Medicare and Medicaid, you might be considered “dual eligible.” Luckily, there are special plans called dual special needs plans or “dual” plans that combine the benefits of both Medicare and Medicaid into one easy-to-understand health plan. If you qualify for Medicare and Medicaid, you may also qualify for a dual plan.

Dual plans go beyond what Medicaid or Original Medicare can offer on their own. With a dual plan, you still retain your current Medicaid benefits, and the best part is that you could receive additional benefits and features compared to Original Medicare, all without any extra cost.

In Texas, you have two options to get your Medicare benefits. The first is through Original Medicare, where the government covers your Medicare benefits directly. The second option is to choose a Medicare Advantage Plan, also known as Part C of Medicare, offered by private companies approved by Medicare. These companies are paid by Medicare to administer your Medicare benefits.

If you decide to join a Texas Medicare Advantage Plan, it will provide you with coverage for both Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). It’s important to note that Medicare Advantage Plans are different from Medicare Supplement Insurance (Medigap) policies.

There are several types of Medicare Advantage Plans available in Texas:

1. Health Maintenance Organization (HMO) plans: Usually, you need to visit doctors, healthcare providers, or hospitals within the plan’s network, except for emergencies or urgent situations. You might also require a referral from your primary care doctor to see specialists.

2. Preferred Provider Organization (PPO) plans: With PPO plans, you pay less when you use providers within the plan’s network and more if you go out-of-network.

3. Private Fee-for-Service (PFFS) plans: Similar to Original Medicare, you can generally see any doctor, healthcare provider, or hospital, as long as they accept the plan’s payment terms.

4. Special Needs Plans (SNPs): SNPs offer specialized healthcare for specific groups, such as those who have both Medicare and Medicaid, reside in nursing homes, or have certain chronic medical conditions.

5. HMO Point-of-Service (HMO-POS) plans: These are HMO plans that may allow you to receive some services out-of-network, but at a higher copayment or coinsurance.

6. Medical Savings Account (MSA) plans: MSA plans combine a high-deductible health plan with a bank savings account, where Medicare deposits some money (usually less than the deductible) to help pay for healthcare services throughout the year. However, MSA plans do not include Medicare drug coverage, so you’d need to join a separate Medicare Prescription Drug Plan.

To enroll in a Texas Medicare Advantage plan, you must have both Medicare Parts A and B and reside within the plan’s service area. People with End-Stage Renal Disease (permanent kidney failure) typically cannot enroll in a Medicare Advantage Plan.

You’ll still need to pay your Part B premium and usually one monthly premium for the services offered by a Medicare Advantage Plan. It’s crucial to compare different plans in your area to understand their costs and benefits before making a decision. Some plans may even have a $0 premium.

Medicare Advantage Plans in Texas must cover all the services that Original Medicare does, except for hospice care, which remains covered by Original Medicare even if you join a Medicare Advantage Plan. Emergency and urgent care will always be covered, even if it’s outside the plan’s service area (excluding international coverage). Additionally, many Medicare Advantage Plans provide extra benefits like dental care, eyeglasses, or wellness programs.

Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). Besides your Part B premium, you usually pay one monthly premium for both medical and prescription drug coverage.

Keep in mind that plan benefits can change each year, so it’s essential to understand how a plan works before enrolling.

If you need Medicare Part D Prescription Drug or Medigap Plans, Ashford Insurance also offers those options.